Compromised Grafts and Flaps

Hyperbaric Oxygen Treatment Therapy can maximize the viability of the compromised tissue thereby reducing the need for re-grafting, or repeat flap procedures.

A number of studies have shown the efficacy of Hyperbaric Oxygen Treatment Therapy on enhancement of flap and graft survival in a variety of experimental and clinical situations.﻿

Animal Studies

Champion and colleagues using a pedicle flap model in rabbits, were able to obtain 100% survival of HBO2 treated flaps (2 ATA for 2 hours twice a day for 5 days), whereas all control flaps had significant areas of necrosis to greater than 40%, attesting to the value of HBO2 therapy in preventing necrosis.

Niinikoski found a 51% improvement in the length of the viable portion of tubed random skin flaps in rats treated with HBO2 (2.5 ATA for 2 hours BID daily for 2 days) compared to air-breathing controls (P < 0.001). The author suggested that enhanced diffusion of oxygen into the area of disturbed circulation was the mechanism for improvement of tissue viability.

Manson and associates, in studies using histochemical staining with ATPase to visualize small blood vessels, demonstrated that capillaries grew distally almost 3 times further in pedicle flaps of pigs that were treated with HBO2, compared with age-matched controls.

Clinical Studies

Perrins and colleagues demonstrated the value of adjunctive HBO2 therapy in skin grafts. Complete survival of grafts occurred in 64% of the treated group as opposed to only 17% of the controls (P < 0.01).

Results of the preponderance of work in the literature clearly show the efficacy of HBO2 with respect to enhancement of skin graft and flap survival. Although each flap problem is unique, a key factor to flap necrosis is tissue hypoxia.

Mechanism of Action

Firstly, the results indicate that viability of flaps can be enhanced by HBO2 by a reduction of hypoxic insult. Other mechanisms of action whereby HBO2 enhances flap survival include secondly, the enhancement of fibroblasts, thirdly promotion of collagen synthesis, and fourthly, increased neovascularization.

Clinical Management

Treatment for compromised grafts or flaps are given at a pressure of 2.0-2.5 ATA and ranges from 90 to 120 minutes. Initial treatment should be twice daily if possible. Once the graft or flap appears more viable and stable, once-a-day treatments may suffice. To be maximally effective, HBO2 therapy should be started as soon as signs of flap compromise appear. Flap viability can be assessed by clinical judgement as well as by a variety of noninvasive and invasive techniques including transcutaneous oximetry and laser Doppler studies.

Utilization Review

Utilization review is required after 20 treatments pre-surgical when preparing a recipient site (such as a radiated tissue bed) for a flap or graft, and following 20 treatments after a flap or graft has been placed into its recipient site.